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HomeMy WebLinkAboutTUSTIN FAMILY CHIROPRACTICGift to Agency Report A Public Document 1. Agency Name City of Tustin rITY Division, Department, or Region (if applicable) Parks and Recreation ____ ..,., 300 Centennial Way Tustin, CA 92780 lrea Code/Phone Number E-mail (714) 573-3333 sking@tustinca.org lgency Contact (name and title) Sarah King, Recreation Coordinator 2. Donor Name and Address Date Stamp ~ TUSTIPd 2S P 2. 25 GIFT TO AGENCY REPORT For Official Use Only ^ Amendment (explain in comment section) Date of Original Filing: 06/25/09 (month, day, year) ^ Individual ~ Other Tustin Family Chiropractic Last Name First Name Name 13771 Newport Ave. Ste 8 Tustin CA 92780 Address City State Zip Code Chiropractic office If "Other" is marked, describe the entity's business activity (if business) or its nature and interests. If applicable, identify the name of each source and the amount(s) solicited or received by the donor for this gift: Tustin Family Chiropractic $ 75.00 $ Name Amount Name Amount 3. Payment Information Date and Amount of Payment (other than travel) 06/23/09 $ (month, day, year) 75.00 (Round to whole dollars) Travel Payment Information (Round to whole donors) Location of Travel Date(s) of Travel Transportation Expenses $ Lodging Expenses $ Meal Expenses $ Other Expenses $ Total Expenses Provide a specific description of the nature and use of the payment for official agency business: Sponsorship for Movies in the Park 2009 Identify the officials for whom the payment was used: N/A Last Name First Name Title DepartmenUDivision Last Name First Name Title DepartmenUDivision 4. Verification 1 have determined that it is in the interests of the agency to accept this gift and use it for the official agency business described above. ~,r~~ ~it _ , , ~h~~~~ _ _-~©~ Sign re o ency Head or Designee Pnnt Name title (mo h, day, year) Comment: (Use this space or an attachment for any additional information.) FPPC Form 801 (June108) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)